The IMCI was implemented in Bangladesh in 2001. Bangladesh adapted the generic IMCI clinical guidelines which recommend that children with one or more danger signs, or any other severe condition, as identified by the health worker of the first level facility will be referred urgently. Although the quality of care achieved in ten IMCI facilities in Matlab, Bangladesh was assessed as high ( El Arifeen 2004) the rates of compliance with referral found to be low. In 2002-03 the compliance rates were less than 37% and had decreased to 17% by the end of 2003 (El Arifeen S, unpublished data). In many settings, children who are referred do not actually attend hospital, which severely limits their appropriate care. This is mainly because the higher level facilities are geographically inaccessible; financial and social constraints also prevent care givers to comply with the referral advice.